Lost Permanent Resident Card Replacement Fee Waiver Request Form

Lost Permanent Resident Card Replacement Fee Waiver Request Form
Use this form to request a waiver of the replacement fee after a permanent resident card has been lost. Please provide accurate details, any available supporting documents, and your declaration before submitting.
Applicant Information
Full legal name
First NameMiddle NameLast Name
Date of birth
MonthDayYear
Date
Country of citizenship or nationality
Current mailing address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Email address
example@example.com
Permanent Resident Card Details
Permanent Resident Card Number (last 4 digits only)
Card Issue Date
MonthDayYear
Date
Place of Issue or Issuing Authority
Is the card currently lost?
Loss Details
Date card was lost
MonthDayYear
Date
Where was the card last seen or believed lost?
Circumstances of loss
Was a police report filed?
Police report reference number (if available)
Fee Waiver Request
Are you requesting a fee waiver for this replacement application?
Reason for requesting the fee waiver
Financial hardship explanation and supporting details
Supporting Documents
Police report copy
Cancelof
Supporting documents
Cancelof
Declaration and Submission
Declaration
Signature
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Date
MonthDayYear
Date
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